#Acute procedural anxiety in adults, Outpatient Setting.
-History and physical performed, see above.
-Patient has significant procedural anxiety.
-Patient declines brief CBT which is also effective for treating acute procedural anxiety. Both meds and brief CBT are 1st-line therapies.
-Prefers a one-time treatment with pharmacotherapy. Since this is not a procedure that will need to be repeated on a frequent basis, I concur.
-Patient education provided as well as alternative treatments, risks, and benefits. Patient expresses understanding.
-Patient promises to have someone drive her to and from the procedure to avoid the effects of any sedation on driving ability.
-Rx: Diazepam (Valium) 2 to 10mg PO x 1, 20 minutes before the procedure.
—END—
Other Treatment Options for Inpatient Setting, etc:
Benzodiazepines
–Midazolam is preferred in the inpatient setting (except for liver patients where lorazepam is better).
–Diazepam (Valium) is preferred benzo for outpatient procedures. It has rapid onset of action, short duration of clinical effects, and good evidence of efficacy
–Lorazepam or temazepam is recommended for patients with Liver problems.
Non-Benzodiazepines
–Melatonin given sublingually is recommended for patients who wouldn’t tolerate benzodiazepines, have medical contraindications or have found them ineffective.
***Lorazepam works for procedural anxiety but has a longer duration of action and longer recovery time compared with diazepam. That’s why in the outpatient, diazepam is better. Lorazepam isn’t a bad choice per se, it’s an acceptable choice, just will keep them drowsy longer.
**Make sure patient has someone drive them to and from the procedure and that you document that. Patients have been in accidents and expensive lawsuits have ensued. Read this article.
“Acute procedural anxiety is an excessive fear of medical, dental, or surgical procedures that results in acute distress or interference with completing necessary procedures. Patients may experience anxiety in anticipation of or during procedures used for screening (eg, mammography), diagnosis (eg, amniocentesis or endoscopy), and treatment (eg, angioplasty or major surgery).” UTD
Benzodiazepines for treatment of procedural anxiety in adults (from UTD)
| Benzodiazepine | Oral dose | Initial parenteral dose | Onset (minutes) |
| Alprazolam | 0.5 mg | Not available | Oral: 15 to 30 (delayed with high-fat meal) |
| Diazepam (1st choice for outpatient procedure) |
2 to 10 mg | 0.03 to 0.1 mg/kg intravenous (2 to 10 mg per dose) | Oral: 15 Intravenous: 2 to 5 |
| Lorazepam | 1 to 2 mg | 0.02 to 0.04 mg/kg intravenous (1 to 4 mg per dose) | Oral: 15 to 30 Intravenous: ≤10 to 15 |
| Midazolam | Oral midazolam is not recommended due to variable response and limited availability (intranasal dosing is provided in footnote Δ) | 0.01 to 0.02 mg/kg intravenous (0.5 to 2 mg per dose) | Intranasal: ≤5 Intravenous: 1 to 3 |
| Oxazepam | 15 to 30 mg | Not available | Oral: 60 to 120 |
| Temazepam | 15 to 30 mg | Not available | Oral: 30 to 60 |
Some patients experience mild symptoms such as nausea, lightheadedness, fatigue, unsteadiness, or psychomotor impairment for up to 24 hours after the administration of sedative agents. This should be made clear to the patient and the patient should be warned not to drive until side effects have completely resolved.
Repeated dose(s) usually equal to one-half of initial dose may be needed 30 to 60 minutes after oral administration or 5 to 30 minutes after intravenous administration, based upon response and duration of procedure.
Δ 5 mg/mL midazolam injection solution may be administered intranasally at a dose of 1 to 4 mg. Onset is within 5 minutes. The injection solution is irritating to nasal passages.
Potency and Half-Life of Various Benzodiazepines
Table from Am Fam Physician. 2000 Apr 1;61(7):2121-2128.
High-potency benzodiazepines |
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Drugs with a short half-life |
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Alprazolam (Xanax) |
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Lorazepam (Ativan) |
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Triazolam (Halcion) |
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Drugs with a long half-life |
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Clonazepam (Klonopin) |
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Low-potency benzodiazepines |
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Drugs with a short half-life |
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Oxazepam (Serax) |
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Temazepam (Restoril) |
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Drugs with a long half-life |
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Chlordiazepoxide (Librium) |
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Clorazepate (Tranxene) |
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Diazepam (Valium) |
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Flurazepam (Dalmane) |
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Sources
http://emedicine.medscape.com/article/2172250-overview#a1
https://www.uptodate.com/contents/treatment-of-acute-procedural-anxiety-in-adults
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1993866/
Am Fam Physician. 2000 Apr 1;61(7):2121-2128.
Other approaches without meds
https://www.mycdi.com/viewpoints/how_to_get_through_an_mri_if_youre_claustrophobic_29
http://www.radiologytoday.net/archive/rt_020609p22.shtml